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This report covers the FHI AIDS Control and Prevention (AIDSCAP) Project (1991-1997). Volume 1 covers regional program overviews, technical strategies, and program support strategies.
Volume 1 |
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Each year as many as 10 scientists participate in the Visiting Scholar's Program at the Center for AIDS Prevention Studies of the University of California at San Francisco. While in San Francisco, they attend seminars on epidemiology, research design, data management biostatistics, and the behavioral and psychosocial aspects of the HIV/AIDS epidemic. But the program's main emphasis is helping the scientists design STI/HIV/AIDS prevention research projects to carry out in their own countries. AIDSCAP/FHI has supported scientists' participation in the program since 1991. Recent behavioral research projects include the following:
Results of these scholars' studies were published in special supplements of the journal AIDS. |
Accomplishments and Results
As part of its commitment to building the capacity of local researchers and institutions, behavioral research within AIDSCAP/FHI (including behavioral research as part of evaluation) enhanced the capacity of more than 150 social scientists from developing countries and more than 100 institutions to conduct HIV/AIDS behavioral research in Latin America, Africa, and Asia. In addition, as part of the training in behavior change communication, AIDSCAP/FHI built capacity in conducting formative research with which to design behavioral interventions. Support for the Visiting Scholar's Program, implemented by AIDSCAP/FHI's partner, the Center for AIDS Prevention Studies at the University of California at San Francisco, provided another model for strengthening local research skills. These approaches encouraged the transfer of knowledge and skills, enhanced the acceptability of research results, and gave local researchers a stake in ensuring that their findings were used to improve prevention programs.
The AIDSCAP/FHI behavioral research program contributed to the scientific knowledge of HIV prevention through peer-reviewed scientific articles and presentations at national and international scientific conferences. This contribution includes more than 50 articles in such journals as AIDS, Journal of the American Medical Association, and Social Science & Medicine and more than 75 presentations of papers at international and regional conferences.
AIDSCAP/FHI behavioral research also demonstrated that theoretical behavior change models developed in the United States provide useful frameworks for examining HIV risk-taking behavior in a variety of cultural and social milieus. The diverse use of different formal theories on HIV risk-taking behaviors confirms that theory can be a valuable and flexible tool for HIV/AIDS prevention in developing countries. Education, information, and persuasion may be changing the HIV-related behaviors of some individuals, but without a theoretical framework, the reasons why some individuals change their behaviors and others do not remain elusive.
Behavioral research under the AIDSCAP Project addressed critical issues of emerging global prevention, such as the role of structural and environmental interventions in reducing HIV incidence and transmission among women in stable relationships and linkages between HIV prevention and care.
AIDSCAP/FHI behavioral research results were used to design effective interventions in many countries. Two examples of these types of interventions are described as follows:
- An application of the health belief model and the theory of reasoned action to an analysis of consistent condom use with commercial sex workers among a sample of 1,472 men living in northern Thailand revealed that both models provided useful frameworks for examining condom use. The theory of reasoned action however, was more useful because it more accurately incorporated peer group effects with sexual risk taking.
- The success of a controlled intervention trial targeting poor young adults (aged 18 to 25) completing their primary and secondary education at night schools in São Paulo, Brazil, led to the development and implementation of a school-based STI/HIV/AIDS prevention program for adolescents in 2,800 public secondary schools in São Paulo state. A total of 300,000 manuals based on the curriculum of this demonstration project were printed and distributed to students throughout São Paulo.
A pilot intervention trial with the Thai military, using the Royal Thai Army's formal command structure as well as informal friendship networks among conscripts, was adapted by the military to provide STI/HIV/AIDS prevention for all recruits.
Lessons Learned and Recommendations
- STI/HIV/AIDS prevention requires a multidisciplinary approach to research.
Research for prevention should not focus exclusively on behavioral issues. Answering many of the most important research questions requires perspectives from such disparate fields as STI management and treatment, social marketing, medicine, counseling, psychology, sociology, epidemiology, communications, and family planning. AIDSCAP/FHI's HIV counseling and testing (C&T) efficacy study provides a good example of a multidisciplinary research project where psychological, behavioral, epidemiological, operations, and cost-effectiveness issues were examined.
- Collaboration with international institutions generates support and a high profile for research.
This collaboration, which brings together highly skilled and experienced researchers, although time consuming, facilitates acceptance of findings because key institutions have been involved in the research process. For example, AIDSCAP/FHI's C&T study was managed by an executive committee that included local principal investigators, AIDSCAP/FHI and CAPS scientists, and collaborators from the Global Programme on AIDS and UNAIDS.
- Large multisite intervention trials have important and specific roles to play in STI/HIV/AIDS prevention.
Such projects can create opportunities to share resources, make cross-site comparisons, and even pool data to enhance statistical power. However, large-scale research projects should be reserved for testing technologies and approaches that have not been rigorously evaluated for efficacy and that have global significance, important policy implications, and complex intervention components.
- Rapid, well-designed, and relatively inexpensive studies are useful for projects that are (1) linked to interventions under development, (2) of local or regional interest, (3) associated with interventions that are culturally specific or that vary by population type, or (4) adaptations of successful interventions from other regions or target populations.
For example, a 9-month qualitative study conducted in Nicaragua identified factors and motivations for risk behaviors among commercial sex workers, their clients, and men who have sex with men. Results provided information critical to the development of a national communication strategy for reaching these groups with prevention messages.
- Matching local research institutions with NGOs that implement interventions is an effective way to organize research.
Such partnerships can provide a sustainable source of technical assistance for NGOs. They also help strengthen local research capacity. For example, a Tanzanian NGO collaborated with a researcher from Muhimbili University on a study on the effect on risk behavior of care and support services for people newly diagnosed with HIV. This collaboration enabled the NGO to continue focusing on providing HIV/AIDS services, while the research consultant provided technical assistance in research methodology and data analysis.
- Ethical review of behavioral research protocols by local review boards ensures that the research is culturally sensitive and responsive to the needs of the communities where it is carried out.
Proposals for research should be reviewed and approved by an ethical review committee whose members are thoroughly familiar with the customs and traditions of the community. A local committee typically offers the best perspective on local sexual and social mores and practices, and often has greater credibility with local scientists than committees overseas. Technical assistance to develop viable and appropriate ethical review committees in host countries contributes to research development.
- Research that helps target audiences identify solutions to their own problems can lead to extremely effective program development.
Such research is particularly useful for designing programs and policies to remove or overcome structural and environmental barriers to behavior change. For example, the Thai "100 percent condom policy" has been hailed as an example of the kind of structural and environmental intervention needed to reduce barriers to individual risk reduction. But would the policy work in other countries? An AIDSCAP/FHI pilot 100 percent condom study in the Dominican Republic involved commercial sex workers, brothel owners, and clients in developing a system of incentives and sanctions that encouraged voluntary compliance with the policy from all involved parties.
- Easy to use research tools -- particularly those that help managers adapt and implement interventions -- can make important contributions to HIV/AIDS behavioral research.
AIDSCAP/FHI developed a module that guides program managers and researchers in organizing focus group discussions and using the data from those discussions to improve interventions. AIDSCAP/FHI also developed a targeted intervention research package that helps STI program managers at the community level conduct formative research to gain a better understanding of the health-seeking behaviors of clients and the attitudes of providers.
- Formative research, which is often an important tool for program development, can also provide information critical to the development of behavioral studies.
For example, formative research conducted in Tanzania for the HIV C&T study showed that it was not possible to accurately measure depression using psychometric scales validated in the United States and western Europe. An alternative scale was developed to more accurately measure depression using physical manifestations that local psychotherapists noted are more common in East Africa.
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Anne, a 22-year-old woman living in Nairobi, decided to get tested for HIV. When she enrolled in the AIDSCAP/FHI C&T efficacy study, Anne received not only an HIV test but also one-on-one personalized counseling. Her negative test result and counseling experience made an impact on her life. As Anne stated, "I used to have many sexual partners before I was counseled and tested for HIV. When I got my results, I decided to get married instead." The effect of voluntary C&T on the risk-taking behaviors of participants like Anne is exactly what researchers conducting the AIDSCAP/FHI C&T efficacy trial want to determine. By comparing a group of people receiving C&T to a group receiving only standard health information, this multicenter, randomized controlled trial will provide valuable information on the efficacy, cost, and side effects of HIV C&T. Anne was just one of the 4,298 volunteers who participated in the study at the AIDSCAP/FHI-funded sites in Kenya and Tanzania and at the site funded by the Joint United Nations Programme on HIV/AIDS (UNAIDS) in Trinidad. Data were collected on sexual behavior, psychological status, knowledge and attitudes about HIV/AIDS and other STIs, and care-seeking behaviors for STIs, and HIV. Preliminary results include the following:
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Challenges for the Future
Biological Indicators
Interest is growing in the use of biologic data, such as STIs and HIV serostatus, as a proxy measure of risk behavior. Data on self-reported behavior may be biased as a result of poor recall and the social stigma associated with reporting risk behaviors. However, the collection of biological data has its own unique set of problems, including the social and psychological impact of receiving positive HIV and STI results, the need to provide STI treatment (which may function as a strong intervention itself), misclassification bias because of the limits of STI diagnostic capabilities, the inability of HIV serostatus to accurately reflect short-term behavior change, and the high costs of biological testing and associated counseling and treatment. Research is needed to determine how biological outcome indicators can best be used to assess behavioral change.
Integrated Reproductive Health
The shifting focus of the pandemic to women and adolescents requires an expanded response incorporating STI/HIV/AIDS prevention into broader reproductive health programs, but few studies have examined how to do so effectively. Little is known about the policy implications of integrating STI/HIV/AIDS, family planning, and maternal and child health services (MCH); about conducting effective risk assessments in family planning and MCH clinics; about how best to expand such services to adolescents; or the potential impact of integration on family planning outcomes, such as fertility rates. Operations research should be conducted to develop the best means of expanding family planning, adolescent health, and MCH services to include STI/HIV/AIDS prevention and services.
Prevention and Care Linkages
Individuals living with HIV/AIDS often experience severe social and psychological stress, particularly soon after learning that they are infected. Study results suggest that individuals who are infected with the virus are more likely to infect others when there are few social and psychological services are available to assist them in coping with their HIV status. As the numbers of infected people increase, more research is needed to understand what types of HIV/AIDS support services that are effective in reducing secondary transmission of HIV infection to others.
Rigorous Behavioral Research
In an environment where indigenous behavioral researchers are in short supply, where HIV prevention remains desperately underfunded, and where rates of HIV infection are increasing, research is needed to identify the interventions that really work so as not to waste already scarce resources.
Beyond Individual Change
Most behavioral research has examined and targeted behavior change at the individual level. While these studies and the resulting interventions have demonstrated some success in changing individual behavior among certain groups, interventions need to focus on levels of social organization beyond the individual. Research is needed to develop tools that measure contextual change, and other societal-level changes.
